Ophthalmoplegia consistent with a pulse is one of the symptoms of direct carotid cavernous sinus fistula. Direct carotid cavernous sinus fistulas are most often due to trauma. A few direct carotid cavernous sinus fistulas are spontaneous, mostly due to rupture of an aneurysm in the cavernous sinus segment of the internal carotid artery, and can be indistinguishable from traumatic on angiography. How to diagnose pulsus-congruent ophthalmoplegia? 1.Headache: Mostly seen in the early stage, the pain is located in the orbital area, and the headache will often be gradually reduced as the disease progresses. 2, intracranial murmur: almost every case, murmur like machine roar continuous, especially obvious at night and quiet, often make the patient unbearable, irritable, seriously affect rest and sleep, auscultation examination in the affected orbital, frontal, external ear mastoid, temporal or even the whole head heard rhythmic murmur consistent with the heart rate; compression of the affected side of the common carotid artery, murmur reduced or disappeared, while compression of the contralateral common carotid artery The murmur does not disappear or is even louder when the contralateral common carotid artery is pressed. The protrusion of the eye is due to intraorbital tissue congestion and edema, and the hand touching the eye can feel the pulsation of the eye and the fluttering sensation when blood flows through. 4. Conjunctival congestion and edema: The affected orbit, inner canthus, conjunctiva, retina and other parts of the veins are congested and edematous, and in severe cases, the conjunctiva turns out of the eyelid and the eyelid closes with difficulty and is complicated by exposure keratitis. 5. Oculomotor disorders: incomplete paralysis of the affected side of the eye, which can be accompanied by diplopia, and abduction paralysis is common. With the presence of pulsating proptosis, intracranial murmur, conjunctival congestion and edema, rhinorrhea and other clinical manifestations combined with the history of head trauma, it is not difficult to diagnose this disease, and cranial CT and MRI show protrusion of the eye and thickening of the intraorbital ophthalmic vein or intracranial drainage vein and accompanying brain tissue edema, TCD and SPECT with the above changes are helpful to the diagnosis, and cerebral angiography is the most important means to confirm the diagnosis, the examination must be routine Internal carotid artery and vertebral artery angiography on both sides must be performed routinely, supplemented by external carotid artery angiography if necessary, to facilitate a clear diagnosis and a comprehensive understanding of the carotid cavernous sinus fistula blood supply and draining veins.